Head and Neck Cancer –How to recognize it in your office

Peter M Hunt, MD, FACSAssociates in ENT/Head & Neck Surgery

DirectorCHI Memorial Head & Neck and Melanoma Centers of Excellence

September 8, 2018

Take Home Message

• The battle in head and neck cancer can be won and lost on the front lines with early detection and referral to those with the proper training and experience to deal with these problems.

Case 1

CASE 2

High index of suspicion

• Risk Factors

• Symptoms (History)

• Signs (Physical Exam)

• Examples

SkinOral cavity / Oropharynx

Who gets the referral?

• Otolaryngologist/Head and Neck surgeon

• Plastic surgeons

• General surgeons

• Endocrine surgeons

• Oral Maxillofacial surgeons

• Dentists

• Dermatologists

Histologic Spectrum of Head and Neck

Cancer

Thyroid

• Thyroid - Differentiated Carcinoma

• Thyroid - Medullary Carcinoma

• Thyroid - Anaplastic Carcinoma

Other Tumors

• Ear and Temporal Bone

➢ Head and Neck - Cutaneous Melanoma/Aggressive carcinoma

• Head and Neck - Sarcoma

• Parapharyngeal Space Tumors

• Skull Base Neoplasms

Upper Aerodigestive Tract

✓ Oral Cavity

• Oropharynx

• Larynx, Supraglottic

• Larynx, Glottic

• Hypopharynx

• Nasopharynx

• Neck Metastases – Unknown Primary

• Nasal Cavity /Ethmoid Sinuses

• Maxillary Sinus

Major Salivary Glands

• Parotid

• Submandibular Gland

Progression to CancerWhich lesion should I refer?

Cancer Statistics 2018

Site Incidence1.Breast 266,1202. Lung 234,0303. Prostate 164,690 4.Colon/Rectum 140,250

5. Melanoma 91,270

12. Thyroid 53,99013. Oral cavity/Oropharynx 51,54021. Larynx 13,150

Cancer Statistics 2018

Site MortalityLung 154,050Breast 40,920Prostate 29,430Colon/Rectum 50,630Melanoma 9,320Oral cavity 2,510Larynx 3,710Thyroid 2,060

Screening challenge for Head and Neck Cancers

• Low incidence/mortality=low priority

• Less public awareness

• No established screening guidelines

SCREENINGAHNS – American Head and Neck Society

• Supports physical exam screening for oral and oropharyngeal cancers in the primary care setting as a part of a routine examination

• Comprehensive oral and head and neck examination in symptomatic or high risk patients as best known method for detecting oral and oropharyngeal cancers

HUMAN PAPILLOMA VIRUS (HPV)AHNS – American Head and Neck Society

• Strongly encourages HPV vaccination of boys and girls for oropharyngeal SCC (9-26 yr.)

Head and Neck Cancer Screening Tools

Risk Factors for Head & Neck Cancer

• Tobacco Products

• Second hand smoke

• Marijuana

• Ethanol Products

•Not primary carcinogen

•Synergistic with tobacco

• Other Factors

•Nutrition

•Human Papilloma Virus

•Genetics

• Chemicals, less common

•Asbestos, Chromium, Nickel, Arsenic, Formaldehyde

Head & Neck CancerSYMPTOMS

Oral Cavity (mouth)• Non-healing ulcer **• Bleeding• Loose tooth; ill-fitting denture• Difficulty speaking• Difficulty swallowing• Pain• Weight loss

Head & Neck CancerSYMPTOMS

Throat

• Ear Pain (from nerves that go to both the throat & ear)• Painful /difficult swallowing• Muffled Voice• Difficult mouth-opening• Weight Loss• Neck Mass Large tonsil

tumor Normal tonsil

Uvula

Head & Neck CancerSYMPTOMS

LARYNX (voice box)

• Hoarseness• Painful/difficult swallowing• Ear pain• Weight loss• Neck mass• Breathing difficulty

TUMOR

Physical Exam

Oral Cavity / Oropharynx

Physical Exam –Salivary gland

Physical Exam – Salivary gland lymphatics

Physical Exam - Thyroid

Physical Exam – Cervical Lymphatics

Head & Neck CancerExpected Lymphatic Drainage

Oral Tongue

R. Byers, et al. Head & Neck. 1988

Head & Neck CancerExpected Lymphatic Drainage

Lower Gingiva

R. Byers, et al. Head & Neck. 1988

Normal Variants

➢ Carotid Bulb

➢ C2

➢ Hyoid bone

Circumvallate Papillae

Inferior Turbinate

TORI

Torus Palatini Torus Mandibularis

High Index of Suspicion

Middle ear effusion

Referred Otalgia

Trismus

Oral Cavity / Oropharynx

Examples

Head & Neck CancerPRE-CANCEROUS LESIONS

Leukoplakia • Means: “White Plaque”• Unable to rub off• 4-18% will develop into cancer• Biopsy

Head & Neck CancerPRE-CANCEROUS LESIONS

Erythroplakia• RED mucosal patch• Persistent, without identifiable source of inflammation• Removal recommended: 20-30% will develop cancer

Verruciform leukoplakia

Granular leukoplakia

Granular leukoplakia Tobacco pouch keratosis

Copyright ©2002 American Cancer Society

From Neville, B. W. et al. CA Cancer J Clin 2002;52:195-215.

Squamous cell carcinoma

Head & Neck Cancer

Molecular Progression of Disease

A series of events leads the cancers to grow and develop

Melanoma and NMSC

Risk Factors for Melanoma /Skin Cancer

• Previous melanoma

• Organ transplant/Immunosuppression

• Atypical Nevi (10-20%)

• 3-20% increased risk of CM

• High Nevus count

• >100 nevi

• Sun / UV exposure

• Childhood sunburn, tanning beds

• Phenotypic traits• Light skin, light eyes, Red/blonde hair, dense freckling

• Familial (10%)

Risk Factors for Melanoma /Skin Cancer

• Cancer prone syndrome? • FAMM – familial atypical mole-melanoma syndrome

• XP – Xeroderma Pigmentosum

XP

FAMM

Skin Cancer - Symptoms

• Non-healing

• Sore

• Itchy

• Scab/Crust

• Rough/Scaly

• Firm nodule

Melanoma : ABCDEF acronym

• Asymmetry

• Border irregularity

• Color

• Diameter

• Evolution

• Funny looking

Friedman RJ et al., 1985

Helpful Patterns

Cheek High Risk SCC – Preauricular metastasis

Scalp High Risk SCC- posterior triangle

Look, Listen, Feel and Gag

• Look at Skin, OC/OP

• Listen for hoarseness

• Feel OC/OP

• Gag Tonsils/BOT

Surgical oncologyRadiation oncologyMedical oncology

Plastic Recon surgeryNuclear medicine

PathologyGenetics

Nurse navigator

CHI Memorial Head & Neck and Melanoma Centers of Excellence

• 1980s – Tumor Conference/pigmented lesions

• 1992 – Lymphatic Mapping /SLNBx

• 2007 – Head and Neck Center of Excellence

• 2016 – Melanoma Center of Excellence